Mindfulness as Cognitive Training a Contribution from Early Buddhist Thought

Transcription

1 Mindfulness as Cognitive Training a Contribution from Early Buddhist Thought Michael Wayne Chaskalson School of Education, University of Wales, Bangor September 2005 This dissertation is submitted in part fulfilment of the requirement for the degree of M.A. of the University of Wales

2 Declarations and Statements This dissertation is submitted in part fulfilment of the requirement for the degree of M.A. Signed Date This work has not previously been accepted in substance for any degree and is not being concurrently submitted for any degree other than the one for which it is now submitted namely Master of Arts of the University of Wales. Signed Date This dissertation is the result of my own independent investigation, except to the extent stated in the acknowledgements, and except for what is explicitly attributed in the text to other sources. Signed Date I hereby give consent for my dissertation, if accepted, to be available for photocopying (subject to copyright regulations) and for inter-library loan, and for the title and summary to be made available to outside organisations Signed Date Acknowledgements I want to express my sincere thanks to the many people who supported me in writing this dissertation, especially:

3 Rebecca Crane and Robert Morrison: insightful supervisors who were open-handed with their time and knowledge. John Teasdale, for stimulating hours of fruitful discussion on Buddhism, the MBAs and contemporary psychology; and for patiently, kindly and generously helping me to develop my teaching ability and understandings. Dharmachari Ruchiraketu, for warm and encouraging support as a teaching colleague. Urgyen Sangharakshita, for his tireless sharing of Buddhist insight. Colin Baker, whose helpful reading of the text was over and above the call of duty. Annette, for her love, unfailing support, and proof-reading!

4 iii Abstract Mindfulness as Cognitive Training: a Contribution from Early Buddhist Thought This comparative study investigates the contemporary use of mindfulness as a clinical intervention alongside the way in which mindfulness was conceived in early Buddhist thought, drawing out convergences and divergences between both contexts. It is especially concerned to investigate whether the early Buddhist conception of mindfulness might cast useful light on contemporary clinical theory and practice. In Chapter 1, the rationale, methodology and focus of the study are described, the research issues are presented and the literary research method that the study uses is discussed. Chapter 2 introduces the concept of mindfulness, showing how it is understood firstly in the Mindfulness-Based Approaches (MBAs) and secondly in early Buddhist thought. Chapter 3 provides a brief overview of the main clinical approaches based in mindfulness and reviews the current research literature in the field. It considers possible mechanisms that might account for the effects of mindfulness training in bringing about symptom reduction and introduces the mindfulness practices taught in MBAs. It shows how the embodiment of mindfulness by the teacher bears upon what is learned and it describes the MBA approach to cognitive training Chapter 4 investigates mindfulness in early Buddhist thought. It shows that mindfulness in that context was conceived as a method of cognitive training aimed at bringing about a change in the way in which the world is perceived. It examines the issue of mental elaboration as it was considered in early Buddhism and discusses the issue of present moment awareness in early Buddhist thought and practice, focusing in particular on the Buddha s discourse on the Four Foundations of Mindfulness. It notes that that the early Buddhist approach to mindfulness focuses to a considerable degree on the issue of cognitive training, especially by way of training one s apperceptions. Chapter 5 provides a summary of the study and brings the main argument to conclusion. It considers the implications of the study for the ways in which mindfulness is used and taught as an approach. It makes recommendations for future theoretical development and suggests lines of further research.

5 v CONTENTS Declarations and Statements Acknowledgements Abstract Table of Contents Abbreviations Introduction i ii iii iv vi vii Chapter One Rationale And Methodology 1 The Research Issue 1 The Context and Background of the Research 2 The Research Questions This Study Addresses 3 Methodology 6 The Focus of this Study 7 Data Collection 8 Analysis of the Data Collected 11 Chapter Two Mindfulness in MBAs and Buddhism 13 What is Mindfulness from the Perspective of the 13 Mindfulness-Based Approaches? The Buddhist Perspective on Mindfulness 19 Chapter Three The Application of Mindfulness in Clinical Contexts 27 The Mindfulness-Based Approaches 27 The Current Research Basis of MBSR and MBCT 30 How Mindfulness May Help in the Clinical Context 32 Exposure 33 Self-Management 34 Relaxation 34 Acceptance 35 Cognitive Change The Structure of a Mindfulness Course and a Review of the Practices Used A Typical Mindfulness Course 40 The raisin exercise 40 The body-scan meditation 42 Sitting meditation 43 Mindful movement 44 Mindful walking 45 Three-minute breathing space 45 The Mindful Didactic Style 46 Cognitive Training in MBAs 48

6 Chapter Four Mindfulness in Early Buddhist Thought 52 Mindfulness and Mental Elaboration 52 Conclusion 76 Chapter Five Conclusion 78 Summary of the Study 78 Conclusions 85 Bibliography 86 Appendix

7 Abbreviations Used in the Study ACT Acceptance and Commitment Therapy CFM Center for Mindfulness CFS Chronic Fatigue Syndrome DBT Dialectical Behaviour Therapy IMSCaR Institute of Medical and Social Care Research MBAs Mindfulness-Based Approaches MBCT Mindfulness-Based Cognitive Therapy MBSR Mindfulness-Based Stress Reduction NICE National Institute for Clinical Excellence RCT Randomised Controlled Trial RP Relapse Prevention UK United Kingdom USA United States of America

8 Introduction The aim of this study is to investigate the relationship between mindfulness as it is currently considered in the context of clinical practice and as it was conceived in early Buddhist thought. It asks whether the early Buddhist conception of mindfulness might cast useful light on the use of mindfulness in the contemporary clinical context. Coming from a long personal background of Buddhist study and practise, my own more recent investigations of mindfulness in the clinical context have enriched my Buddhist practice. This study sets out to investigate whether this might be a two-way street. Could mindfulness-based clinical interventions be further enriched by an investigation of Buddhist ideas and practices? As will be shown, contemporary teachers of mindfulness in the clinical context tend, with good reason, to underplay the Buddhist background to mindfulness practice. Nonetheless, the question arises of whether an examination of that background might not yield valuable information. What might Buddhism, with its 2,500 year history of mindfulness practice, have to say to those using mindfulness techniques to address the issues of chronic pain, stress, depression relapse and other disorders? This is not to suggest that patients need to be confronted with Buddhist teaching when engaging with these approaches. Common-sense suggests that that would often hinder more than it would help. Nonetheless, the insights contained in the Buddhist tradition transposed into the clinical context might help instructors in the Mindfulness-Based Approaches (MBAs) deepen their understandings of mindfulness and so enhance their teaching methods. The investigation that follows has offered me the opportunity to deepen my understanding of both of these traditions one spiritual, the other clinical. It is my hope that it will be of some use to practitioners in both disciplines.

9 1 Chapter One: Rationale and Methodology Aims of Chapter One This chapter begins with a brief statement of the research issue the study addresses. It goes on to outline the context from which I am undertaking the research and it lays out the rationale of the study in more detail, focusing on the specific questions asked. It then discusses the research tools used, focussing in particular on the question of literature research as a valid methodology. It describes the kind of evidence used in the study and concludes with a discussion of how the evidence gathered was analysed and processed. The Research Issue Evidence suggests that mindfulness-based clinical interventions are effective (Baer, 2003; Grossman et al. 2004; Segal et al. 2003; Ma and Teasdale, 2002), and Mindfulness-Based Approaches (MBAs) are currently being used in a wide variety of clinical contexts (Baer, 2003). But researchers in the field have only recently begun to operationalize the concept of mindfulness and to provide coherent definitions of it (Bishop et al., 2004). The aim of this study is to investigate whether the approach to mindfulness that is found in traditional Buddhist thought and practice has anything to offer the task of operationally defining mindfulness for clinical and clinical research purposes. In particular, this study focusses on the traditional Buddhist approach to mindfulness as a form of cognitive training, and it asks whether that aspect of mindfulness has been sufficiently acknowledged in the literature on MBAs to date. At first glance the overlap between Buddhism and MBAs may not be apparent. Mindfulness itself, however, is, in its origins, distinctively and quintessentially Buddhist (Gombrich, 1988, p.64). This study attempts to discover the extent to which certain key Buddhist ideas have come to inform MBAs and to ask whether there is anything more to be found in Buddhist thought and practice that might further enrich the clinical application of mindfulness. The Context and Background of the Research As a committed Buddhist, a meditator, writer and teacher of Buddhism and associated disciplines, I have more recently been training in the delivery of mindfulness-based stress reduction both with members of the Centre for Mindfulness Research and Practice that is part of the University of Wales, Bangor, and with Dr. John Teasdale, one of the co-founders of Mindfulness-Based Cognitive Therapy(MBCT), in Cambridge.

10 2 In the course of this training I have come to notice more and more the considerable overlap between Buddhism and MBAs and also to begin to question whether there might be more in traditional Buddhism, both in terms of teaching and practices, than is currently acknowledged in the literature on MBAs or in their clinical applications. Kabat-Zinn, perhaps the most pre-eminent proponent of MBAs and one of the founders of the approach, clearly acknowledges the Buddhist contribution to the field, seeing the Buddha s teachings as a coherent phenomenological description of the nature of mind, emotion, and suffering and its potential release, based on highly refined practices aimed at systematically training and cultivating various aspects of mind and heart via the faculty of mindful attention (Kabat-Zinn, 2003, p. 145) But as I have progressed in my training in MBAs, certain questions have occurred to me again and again. Is there more to mindfulness than is explicitly acknowledged within MBAs? The Buddhist literature on mindfulness is rich and diverse. Could an investigation in this area, that focusses on discovering material that might have clinical application, uncover more than has thus far been used? Clearly, there are good grounds not to over-emphasise the Buddhist background to mindfulness within the context of MBAs. Especially in clinical contexts, the approaches need to be seen as secular and equally open to people of all religions or none. Thus, Kabat-Zinn (1991), while acknowledging the Buddhist background to mindfulness, stresses that it is a universal human faculty that can be practised apart from Buddhism or Oriental culture. Some authors take this further. The term Buddhism, for instance, doesn t even occur in the index of Segal et al. (2002). This is not a problem, as such, and it would be a great shame if the potential clinical value of mindfulness was lost because of a misplaced over-emphasis on its religious origins. At the same time, it can be asked whether Buddhism, with its 2,500 year history of addressing the issue of human suffering, might have more to offer those engaged in the clinical endeavour to alleviate distress. Beginning to research this area, I came to realise that one aspect of Buddhist thought, at least, that seems not to be acknowledged in the literature on MBAs is the use of mindfulness

11 3 meditation as an explicit form of cognitive training. This issue became the central focus of my research and it is around my findings in this area that this study is based. The Research Questions This Study Addresses The specific questions addressed in this study are as follows: First of all, What part does cognitive training play in the early Buddhist conception of mindfulness practice? Then, to see whether MBAs might be further enriched by the inclusion of concepts and practices from Buddhism, it asks How might the Buddhist approach to cognitive training further enrich our understanding of MBAs? This study may have several values By making explicit the traditional relationship between mindfulness and cognitive training, the mechanisms whereby mindfulness produces beneficial change might be further illuminated for researchers and instructors in MBAs. There is still much discussion in the field of MBAs around the operational definition of the construct of mindfulness (Baer et al., 2004; Bishop, 2002; Bishop et al., 2003; Dimidjian and Linehan, 2003; etc.). An investigation into the Buddhist origins of the construct might usefully inform that discussion. By making explicit the relationship between Buddhism and MBAs, MBA instructors might gain a clearer understanding of the background to their approach. This enriched understanding might lead to a more deeply informed presentation of their material. As Teasdale et al. (2003) point out Within the tradition in which mindfulness training was developed, mindfulness was never seen as an end in itself, but as one part of a comprehensive, multifaceted path to resolve a clearly formulated

12 4 problem. The same is likely to be true of effective clinical use of mindfulness training. (p.158) Anecdotal evidence suggests that there is an increasing interest in teaching MBAs at Buddhist centres in the West. In Britain and Ireland, for example a Google search, carried out on the 14 th of August 2005, revealed that there are courses based on MBAs currently available at Buddhist centres in Dublin, Manchester, Edinburgh, Glasgow, Cambridge, Brighton and London. This study might help to clarify the approaches taken at such centres, delineating, for example, what might best be left in the territory of Buddhism and what might usefully be carried over into the domain of MBAs. Dimidjian and Linehan (2003) ask whether or not it might be clinically advantageous to include in MBA treatment programmes a more explicit discussion of the goals of mindfulness as practiced in a spiritual context and they wonder whether the clinical practice of mindfulness is diluted by a failure to discuss these issues explicitly. do clients receive a watered down version of what they could receive if clinicians did not separate out these aspects? (Dimidjian and Linehan, 2003, p.167). There are arguments to be made on both sides of this debate, and this study might usefully inform a discussion of the issue. Teachers in clinical settings may find their work enhanced and enriched by the inclusion of elements more explicitly drawn from the religious or spiritual dimension of mindfulness. Those teaching MBAs in Buddhist centres may be tempted to use the teaching as a vehicle for recruitment or proselytization. This study might usefully inform a discussion of the appropriate boundaries between the religious and the clinical aspects of mindfulness as it is taught in the context of MBAs. Methodology In the social sciences, two principal approaches to designing research are recognised: quantitative and qualitative. The former are intended to establish objective evidence by gathering and analysing data that are measurable by experimentation, for instance, or the statistical analysis of

13 5 questionnaire results. The field of quantitative research in respect of MBAs grows almost daily. Grossman et al s (2004) meta-analytic review of the field of mindfulness literature, for example, included 64 studies. This study, however, has a different concern. Its objects are theoretical. It deals with a comparison of concepts and, to a lesser extent, values, and as such it might be thought of as a form of qualitative research. McLeod s (1994) description of qualitative research as a process of systematic enquiry into the meanings which people employ to make sense of their experience and guide their actions (p. 78) fits the approach taken here. But qualitative methodologies in general are aimed primarily at obtaining information from people, and that is not what this study sets out to do. Elias (2001) states that there are no published guidelines on research design and methodology for the kind of comparative study here proposed. Rather, he suggests, authors take their structure and style from similar studies. In support of this view, I have been unable to find specific references to the methodology and structure of a theoretical cross-disciplinary literature review such as this is. Cooper (1989); Wolcott (1991); Ely, M., et al. (2001); and Golden-Biddle, K & Locke, K., (1997); in their writings on the presentation of qualitative research include details of literature reviews, but these are specifically in support of field data and are not aimed at the critical or comparative analysis of the literature itself especially as regards its theoretical content. This study is a form of literature research, and the approach taken is relatively simple. Once I had narrowed the focus of the study to the issue of mindfulness as described in early Buddhist literature and in the literature on MBAs as a means of cognitive training, the field of material available for comparison became manageable and relatively straightforward to cross-correlate. That said, it is important to acknowledge that such comparative studies have their limitations. The field of early Buddhist literature is large and there may well be texts that I have not consulted that would cast further light on the study. What is more, as a researcher I bring to my readings my own inevitable biases. Other might well make different interpretations. The Focus of this Study Any study concerned with investigating all the Buddhist methodologies for the alleviation of human suffering would run to many thousands of pages. The present study is necessarily more closely focussed. To begin with, I have chosen to restrict the study to issues arising out of a consideration of mindfulness, not some of the other methodologies that are commonly brought to bear in the Buddhist quest for awakening. As already noted, I began my research by looking into the parallels between Buddhism and MBAs. It soon became clear that there was a need to

14 6 narrow the field and so I came to focus on early Buddhism, particularly the Pÿli material. Bishop et al. s (2004) operational definition of mindfulness as used in clinical contexts provided a useful starting point. They see it as a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one s experience within an orientation of curiosity, experiential openness, and acceptance. [It is] a process of gaining insight into the nature of one s mind and the adoption of a decentered perspective on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence). (Bishop et. al., 2004, p.234) This is a rich definition, compacting much into few words, and it provided a list of qualities to investigate: mental elaboration, present moment awareness, curiosity, openness and acceptance, insight and the true nature of mind, decentring, subjectivity, and impermanence. It soon became clear that within a 20,000 word study one could never do justice to all of these concepts as they occur in the Pÿli literature and the study had to be focussed still further. One issue stood out. Investigating the issues of mental elaboration and present moment awareness in the Pÿli 1 Buddhist literature, I began to see the extent to which that literature advocated mindfulness practice as an explicit form of cognitive training and I sought parallels to that in the literature on MBAs. That, then, became the focus of this study. Data Collection The question arises as to which Buddhist traditions and which corresponding elements of Buddhist literature one should draw upon. This study does not proceed from the presumption that any one part of the Buddhist canonical literature (Pÿli, Sanskrit, Chinese and Tibetan) is intrinsically more valuable than any other. Nor does it hold out for the value of one tradition over another it does not presume that the Theravÿda 2 is more valuable than Zen, or that the Tibetan Vajrayÿna 3 is more valuable than the Chinese Pure Land approaches, for example. Nonetheless, out of this An early Indian language, allied to Sanskrit and, like Sanskrit, no longer in current use. The oldest surviving Buddhist school, currently predominant in South and South-East Asia. A highly ritualised approach to Buddhism currently most commonly found in Tibet

15 7 vast field of teaching, literature and tradition one must make choices, otherwise one might well be swamped in source literature. For that reason I have chosen to confine this study to early Buddhist literature and particularly to the Pÿli literature which, being the earliest surviving complete canon preserved in an Indian language 4, is in all likelihood nearest to some of what the historical Buddha himself might have taught (Sangharakshita, 1985). At the same time, it must be noted that since Buddhism was preserved as a strictly oral tradition for at least 200 years before the first texts were written down, the exact words of the Buddha himself have been irretrievably lost in the mists of time. In the past half century or so, particularly with the increasing recognition of the complex history of the early communities and texts, it has come to be widely agreed that nothing definitive can be known about the Buddha himself or the Buddhism he founded. (Ray, 1994, p. 9) In search of greater authenticity, I have chosen to rely primarily on canonical rather than secondary literature for most of my sources, although I have drawn at times on contemporary scholars of that literature and on the writings of contemporary Buddhist teachers of mindfulness. Having decided to focus the Buddhist aspect of my research in this way, the collection of relevant data became relatively simple. There are a small number of texts which have, between them, come to be regarded as the locus classicus of the Pÿli teachings on mindfulness (Sangharakshita, 1985). Going to these texts, as original (translated) source material, as well as to contemporary scholarly commentary upon them, and following paper trails through references, footnotes and bibliographies, I was able to build up a picture of the early Buddhist attitude to mindfulness as a form of cognitive training. So far as the literature on MBAs is concerned, the field is smaller. In her meta-analytic study of the efficacy of mindfulness-based interventions, Baer (2003) focussed her attention on the 8-10 week Mindfulness-Based Stress Reduction (MBSR) programme as well as programmes using Mindfulness-Based Cognitive Therapy (MBCT). She decided not to use studies of the other MBAs she recognised Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), or Relapse Prevention (RP), all of which use mindfulness to one extent or another because she 4 The only other surviving equivalent canon has been so far preserved only in Chinese. It is not yet available in English.

16 8 found no studies that examined the mindfulness component of these independently of other behaviour change strategies they employed. For that same reason, this study is largely confined to an examination of mindfulness as a clinical intervention in the contexts of MBSR and MBCT. With this focus, the task became more manageable. The field of literature on MBAs although large, is at least digestible. There is a small handful of published books and the number of papers published in the journals of applied and theoretical psychology, behavioural and psychosomatic medicine, psychiatry, and allied disciplines, although growing almost by the day, is still small enough to become familiar with. Since almost all of this literature is now available on the Web in digital form, I downloaded most of the references I needed via the University of Bangor library website. Where I was not able to obtain an article by that means, the University of Cambridge library or the British Library inter-library loans service were able to provide copies. I have been fortunate to be guided in my reading of this literature by Rebecca Crane, Director of Training at the Centre for Mindfulness in the Institute of Medical and Social Care Research (IMSCaR) that is part of the University of Wales, Bangor. Ms. Crane is one of my two cosupervisors for this study. I was also aided by Judith Soulsby, the research officer at IMSCaR, whose familiarity with the published mindfulness research material was very helpful. I have been equally fortunate to be guided in my reading of the Pÿli literature by Dr. Robert Morrison, a scholar of that literature and my co-supervisor. What of the literature I don t already own was easily obtainable from the Cambridge Buddhist Centre library or from the Web. In this way I was able to consult a number of dictionaries of Pÿli and Sanskrit, as well as books by contemporary scholars of Buddhism and teachers of mindfulness in the Buddhist context. Besides the Cambridge Buddhist Centre library, the library of the Western Buddhist Order in Birmingham has been a useful resource. Analysis of the Data Collected Focussing on the issue of mindfulness as a means of cognitive training, it became a relatively simple matter to see how the descriptions of mindfulness practice in the early Buddhist texts and in the literature on MBAs bore upon that theme. Mindfulness, in its clinical application, has begun to be operationally defined as a conceptual construct and the literature around the issue of definition is clear and not in need of a great deal of further analysis. It is, however, amenable to criticism, or at least to suggestion as to how it might be enriched, and that is a key aspect of this study.

17 9 The task of understanding how the writers of the Pÿli literature understood mindfulness is more complex, for the texts require a certain amount of interpretation. In making such interpretations I have relied on a triangulation between the Pÿli texts themselves, the scholarly commentaries upon them, and my own lived experience of mindfulness. In doing this, I am aware of the prospect of subjective bias influencing my conclusions, but that must always be the case where an act of interpretation is called for. I can say, however, that in this process I was never aware of any significant tensions within the triangulation: there have been none of the dissonances that occur when an interpretation appears to be in some way forced. The final aspect of the task was cross-correlation. Having discovered what the early Buddhist literature and the literature on MBAs had to say of mindfulness as a means of cognitive training, the study then relates one to the other and draws its conclusions. Summary of Chapter One This chapter has outlined the rationale for this study and posed the research questions that it asks. It has delineated the focus of the study and described the research method, acknowledging its limitations. The study now goes on to present an overview of mindfulness itself, both from the perspective of MBAs and of early Buddhist thought.

18 0 Chapter Two: Mindfulness in MBAs and Buddhism Aims of Chapter Two This chapter introduces the concept of mindfulness, firstly noting how it is considered in the context of MBAs and then in the context of early Buddhist thought. It notes the prospect of there being an overlap between early Buddhist thought and MBAs, both in terms of their common application of mindfulness to their endeavours and in their intent to address the issue of human suffering. What is Mindfulness from the Perspective of the Mindfulness-Based Approaches? At the outset, it is important to recognise that the term mindfulness may have different shades of meaning in Buddhism and MBAs. In the context of MBAs, Kabat-Zinn s (1994) definition of mindfulness is widely used. He suggests it is a particular way of paying attention: on purpose, in the present moment, and nonjudgementally. (Kabat-Zinn, 1994 p.4) A search on scholar.google.com yields more than a dozen citations of this definition in scholarly journals. Crane (2004) describes mindfulness as simply being aware of what is going on, as it is arising, connecting deeply and directly with this and relating to it with acceptance; a powerful act of participatory observation. (Crane, 2004, p.2) Although acknowledging that the concept of mindfulness has its origins in Buddhism, Kabat-Zinn and other writers on MBAs maintain that its essence is universal (Kabat-Zinn, 2003; Grossman et al., 2004; Bishop et al., 2004). As a way of paying attention, says Kabat-Zinn (1991), it can be learned and practiced without appealing to Oriental culture or Buddhist authority to enrich it or authenticate it (p. 12). Although acknowledging that the construct of mindful awareness originated in earliest Buddhist documents, Grossman (2004), maintains that it is neither religious nor esoteric in nature (p.36). Rather, it may be seen as

19 1 a form of naturalistic observation, or participant-observation, in which the objects of observation are the perceptible mental phenomena that normally arise during waking consciousness. (Grossman, 2004, p.36) This state of accepting, present-centred awareness, Kabat-Zinn (2003) asserts, is one which most people experience from time to time. We are all mindful to one degree or another, moment by moment. It is an inherent human capacity. (Kabat-Zinn, 2003, pp ) In the mindful state, we are fully and directly present to current experience, in a way that is unclouded by thought-based feelings or concepts about that experience (Crane, 2004). For many, though, life is lived habitually, within a fog of preconceived preoccupation. We may never be quite where we actually are, never quite touch the fullness of our possibilities. Instead we lock ourselves into a personal fiction that we already know who we are, that we know where we are and where we are going, that we know what is happening all the while remaining enshrouded in thoughts fantasies and impulses, mostly about the past and about the future. (Kabat-Zinn, 1994, p. xv) There is a significant evolutionary advantage in being able to move our awareness into the future or the past. It is an important human skill. But it can become problematic to the point of pathology when it links in with two other human skills mentioned below. The first of these is sometimes referred to in the literature as automatic pilot. Teasdale et. al. (2000) use this notion to illustrate the distinction between mindfulness and mindlessness, referring to the common experience, when driving along a familiar route, of suddenly realizing that one has been doing so for miles on automatic pilot, unaware of the road or other vehicles, preoccupied with planning future activities or ruminating on a current concern.

20 2 By contrast, mindful driving is associated with being fully present in each moment, consciously aware of sights, sounds, thoughts, and body sensations as they arise. When one is mindful, the mind responds afresh to the unique pattern of experience in each moment instead of reacting mindlessly to fragments of a total experience with old, relatively stereotyped, habitual patterns of mind. (Teasdale et al, 2000, p. 618) The second skill is discrepancy monitoring. much of cognition occurs in the service of goals. We are constantly engaged in a process of comparing what is with what is desired, and much of our mental life and behavioral organization functions in the service of reducing any discrepancies. When there is a discrepancy, negative affect occurs (e.g., fear, frustration) setting in motion cognitive and behavioral sequences in an attempt to move the current state of affairs closer to one s goals, desires, and preferences ). If the discrepancy is reduced, then the mind can exit this mode and a feeling of well-being will follow until another discrepancy is detected, again setting this sequence in motion. (Bishop et al., 2004, p. 236) The ability to engage in complex activities, such as driving a car or operating a computer, without having to consciously think of what one is doing at each step, is a significant advantage. So is the ability to monitor discrepancies between how things currently are and how they might be. These three skills the ability to dwell in the past or future, automatic pilot and discrepancy monitoring can, however, come together pathologically. The processes of wishing to avoid unhappiness and to achieve happiness while constantly monitoring the discrepancy between how things are and how they should be or have been, when it is unconscious and on automatic pilot, can result in depressive rumination. These ruminations are patterns of thinking, feeling and behavior that are unhelpful because they simply circle round and round without producing a resolution.

21 3 Ruminating about a problem feels as if it should bring a solution, but such ruminations can often exacerbate the situation. (Segal et al., 2002, p. 158) Why am I feeling this way? I am usually more cheerful than this. I shouldn t be feeling this way. Ruminations such as this can trap us into trying to deal with negative affect by using intellectual problem-solving techniques as if we were playing chess and might suddenly find the right move that wins us the game (Segal et al., 2002). It is as if we believe that our usual, clever, problem-solving abilities should be able to sort out all our problems. The feeling is very compelling and cannot be easily switched off. In fact, it is unlikely that persons would voluntarily give up their old ways of trying to deal with their problems by ruminating about them unless they had sampled another approach. (Segal et al., 2002, p.159) The analytical skills of problem solving, that are so useful in many areas of our lives, ironically can often increase our difficulties when brought to bear on the experience of mental or physical suffering (Crane, 2004). Mindfulness, on the other hand, confers upon one the skill of being able to disengage from such analytic thought processes and to bring one s awareness back to the actuality of the present moment, creating an opening to the possibility of a wiser response to distress. The core aim of MBAs is to equip patients with ways of responding to stress, depression, or other problems, allowing them to step out of the mental reactions that often exacerbate their difficulties and interfere with effective problem solving. Mindfulness can enable one to see that the best way to achieve one s goals might be to let go of the attempt to strive for results and instead begin to see and accept things just as they are, in the present (Crane, 2004). Grossman et. al., (2004, p. 36) suggest that the assumptions underlying MBAs are as follows: (1) Humans are ordinarily largely unaware of their moment-tomoment experience, often operating in an automatic pilot mode.

22 4 (2) We are capable of developing the ability to sustain attention to mental content. (3) Development of this ability is gradual, progressive and requires regular practice. (4) Moment-to-moment awareness of experience will provide a richer and more vital sense of life, inasmuch as experience becomes more vivid and active mindful participation replaces unconscious reactiveness; (5) Such persistent, nonevaluative observation of mental content will gradually give rise to greater veridicality of perceptions. (6) Because more accurate perception of one s own mental responses to external and internal stimuli is achieved, additional information is gathered that will enhance effective action in the world, and lead to a greater sense of control. We will return to consider some of the issues arising from this analysis in due course. For now, though, having provided an overview of mindfulness from the perspective of MBAs, let us briefly consider the Buddhist perspective. The Buddhist Perspective on Mindfulness In the context of Buddhism, the term mindfulness is generally taken to be a translation of the Pali sati which is the equivalent of the Sanskrit term smœti. Rhys-Davids and Stede, (1993) in their Pali-English Dictionary link sati etymologically to the Vedic Sanskrit term smœti, that connotes memory or mental retention (Monier-Williams, 1999). Indeed sati, in the sense of memory, occurs on several occasions in the Buddhist literature (Anÿlayo, 2003). Where the term is rendered as mindfulness, however, it is because the presence of sati enables one to remember what is otherwise only too easily forgotten: the present moment (Anÿlayo, 2003, p ). Sati represents the ability

23 5 to simultaneously maintain in one s mind the various elements and facets of a particular situation. This can be applied to both the function of memory and to awareness of the present moment. (Anÿlayo, 2003, p ) Mindfulness is valued in Buddhist thought as one of the chief means of making spiritual progress. Thus the Dhammapada, an early text revered in both the Pali and Sanskrit wings of the tradition (Sangharakshita, 2001) praises mindfulness as follows: 29. Mindful among the unmindful, wide awake among the sleeping, the man of good understanding forges ahead like a swift horse outdistancing a feeble hack. 30. By means of mindfulness Maghava attained to the chieftaincy of the gods. Mindfulness is always praised, unmindfulness always despised. 31. The almsman who delights in mindfulness and who regards unmindfulness with fear advances like fire, burning up fetters gross and subtle. 32. the almsman who delights in mindfulness and who regards unmindfulness with fear is not liable to regression. He is in the presence of Nirvana. (Sangharakshita, 2001, pp ) The person who delights in mindfulness is in the presence of Nirvana. Nirvana is used here as a synonym for bodhi awakening the goal of the Buddhist spiritual life. From the Buddhist perspective, the vast majority of people are not awake. We have not realised our fullest potential and live our lives in a fog of delusion. And yet every one of us has the capacity to be clearer, wiser, happier, and freer. We have the capacity to penetrate directly to the heart of reality to come to know things as they really are. (Kulananda, 2003, p.8)

24 6 This penetration, to the very heart of reality, is what the Buddha termed awakening, and the Buddhist project, certainly in terms of the early tradition with which we are dealing, is to progress towards it by degrees. As the Buddha put it in the Pahÿrÿda Sutta (AÇguttara Nikÿya, ii.47), just as the ocean slopes gradually to the depths, so the approach to awakening is gradual and by increasing degrees. Following the path opened up by the Buddha, the mindful person according to the Dhammapada quote above is not liable to regression, but forges ahead towards awakening, burning up the fetters that bind him or her to the unawakened state. Here we see one of the chief distinctions between Buddhism and MBAs. MBAs seek to alleviate distress. The explicit goal of Buddhism is to eliminate it altogether. MBAs seek to alleviate suffering by training clients or patients in more skilful ways of coping with stress (Grossman et. al., 2003), managing chronic pain (Kabat-Zinn, 1991), treating depression relapse (Segal et al., 2002). The goal of Buddhism is more explicitly all-encompassing. The achievement of Awakening involves the deepest understanding of the nature of suffering, its cause, its cessation, and the way leading to its cessation. (Gethin, 1998, p.15) The early Buddhist texts present the Buddha s teaching as the solution to a problem. (Gethin, 1998, p.59) The problem, which is the fundamental problem of life (Gethin, 1998, p.59), is termed dukkha in Pali, duåka in Sanskrit. Loy (2000) translates it helpfully as lack, a sense, he says, that emerges from our profound and repressed intuition that we are not real. our most troublesome repression is not sexual wishes, nor even death fears, but awareness of non-self the intuition that I am not real which we become conscious of (the return of the repressed ) as a sense of lack infecting our empty core. It is the deep feeling

25 7 we all have that something is wrong with me, that something is missing. (Loy, 2000, p.1) Most commonly, however, translators render the term as suffering and although that lacks the existential shades of meaning that Loy s translation neatly highlights, it does account for the simpler sense of physical suffering that occurs when, for example, we cut ourselves or break a leg. Since these feelings, too, are spoken of as dukkha (Nyanatiloka, 1972), I will follow the convention for the time being in using the term suffering. The Buddha was quite explicit about the intent of his teaching: what I teach is suffering and the cessation of suffering. (Majjhima Nikaya i 140) As he observed in his teaching of the Four Noble Truths, suffering is caused by thirst and his approach to the cessation of suffering was by way of the complete cessation of what is known in Pÿli as taýhÿ. Literally thirst, it is a state of wanting, of unfulfilment, from the most primitive and crude depths to the most refined heights (Morrison, 1997). Best understood as a metaphor that attempts to capture the most pervasive affective characteristics of the unawakened state, it is the source from which spring the various means of seeking some form of gratification and purpose in life (Morrison, 1997, p. 148). Addressing his first monastic followers (bhikkhus) after his awakening, the Buddha put it like this (each verse will be interspersed with explanatory commentary): This, bhikkhus, is that middle way awakened to by the Tathÿgata, which gives rise to vision, which gives rise to knowledge, which leads to peace, to direct knowledge, to enlightenment, to NibbÿÝa. (Saçyutta Nikÿya, V. 56) Tathÿgata, The One Who Have Thus Come or The One Who Has Thus Gone, is a synonym for the Buddha. NibbÿÝa is the Pÿli equivalent of the Sanskrit Nirvana a synonym for awakening.

26 8 Now this, bhikkhus, is the noble truth of suffering: birth is suffering, aging is suffering, illness is suffering, death is suffering; union with what is displeasing is suffering; separation from what is pleasing is suffering; not to get what one wants is suffering; in brief, the five aggregates subject to clinging are suffering. (Saçyutta Nikÿya, V. 56) The five aggregates referred to above are the five aspects into which the Buddha summed up all the physical and mental phenomena of existence and which appear to the unawakened as their ego or personality (Nyanatiloka, 1972). These aspects are one s physical body and its senses; feelings that are pleasant, unpleasant or neutral; ideas and concepts; desires and volitions; and self-consciousness (Gethin, 1998). That the five aggregates all of unawakened human experience are marked by suffering is the First Noble Truth. Now this, bhikkhus, is the noble truth of the origin of suffering: it is this thirst 5 which leads to renewed existence, accompanied by delight and lust, seeking delight here and there; that is, thirst for sensual pleasures, thirst for existence, thirst for extermination. (Saçyutta Nikÿya, V. 56) Implicit in the phrase renewed existence is the Buddhist idea that all existence is contingent. In particular, the human personality or selfhood, constantly subject to change, is a deluded construct of the unawakened mind. As we have seen, the Buddha of the early texts spoke of the human personality as made of five aggregates, and each of these aggregates, he said, being subject constantly to change and therefore having no fixed, enduring existence should be apprehended with the clear understanding that this is not mine, this I am not, this is not my self (Majjhima Nikÿya, i ). In other words, although we do experience, it is a mistake to infer, in a Cartesian sense, that because we experience we exist as fixed and separate selves. Our experience always comes down to one or another of the five aggregates: a specific sense datum, a feeling, an idea, a wish or desire, and a consciousness of one thing or another. Each of these is in a state of constant 5 Here, as elsewhere, I have followed Morrison (1997) in rendering taýhÿ as thirst, rather than as craving, as Bhikkhu Bodhi, otherwise the translator of this text, has done.

27 9 change. From one moment to the next, none remains for more than an instant. Apart from these experiences, one can never actually come upon or experience the I that is having the experience. How can we know it is there? We cannot conceive of consciousness apart from all of these changing details and if we abstract all the particular details of consciousness we are not left with a constant, individual self but a blank, a nothing. (Gethin, 1998, p.138) As each of the aggregates changes so our existence is continuously renewed and the engine driving this process, the Buddha says, is thirst driving us in constant quest for being and for non-being. When states are pleasant we wish them to continue. When they are unpleasant we wish them to be eliminated. This is the unawakened human condition: a constant vacillation between thirst and aversion continuation and elimination. Thirst, says the Buddha in the Saçyutta Nikÿya, is the cause of suffering. This is the Second Noble Truth. Now this, bhikkhus, is the noble truth of the cessation of suffering: it is the remainderless fading away and cessation of that same thirst, the giving up and relinquishing of it, freedom from it, nonreliance on it. (Saçyutta Nikÿya, V. 56) The Third Noble Truth asserts that with the cessation of thirst, suffering, too, ceases. Now this, bhikkhus, is the noble truth of the way leading to the cessation of suffering: it is this Noble Eightfold Path (Saçyutta Nikÿya, V. 56) The Fourth Noble Truth is that there is a path leading to the cessation of suffering. In this particular formulation, the path is spoken of as the Noble Eightfold Path, comprising right view, right understanding, right speech, right action, right livelihood, right effort, right mindfulness and right concentration. Although the explicit goal of Buddhism is the complete cessation of suffering, whereas for MBAs the goal is its amelioration, clearly there is the possibility of a considerable overlap between them, for what leads to the cessation of suffering might also, at an earlier stage of its practice, lead to

28 0 its amelioration. Exactly what this overlap might be, how it might be understood, what its boundaries are, and whether it might be usefully extended, is the topic of this study itself. Summary of Chapter Two This chapter has reviewed how mindfulness is considered firstly in the context of MBAs and then in the context of early Buddhist thought. It has noted the different aims of both projects. MBAs seek to ameliorate suffering, Buddhism aims to eliminate it. But it has also noted the prospect of there being an overlap between early Buddhist thought and MBAs, both in terms of their common application of mindfulness to their endeavours and in terms of their intent to address the issue of human suffering. The next two chapters will review in more detail how mindfulness is conceived and applied, firstly in the context of MBAs and then in the context of early Buddhist thought.

29 1 Chapter Three: The Application of Mindfulness in Clinical Contexts Aims of Chapter Three This chapter begins by providing a brief overview of the main Mindfulness-Based Approaches (MBAs). It then presents a brief review of some of the current research into Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT). It goes on to consider mindfulness from a clinical perspective, and it discusses the possible mechanisms that might account for its effect in bringing about symptom reduction. It then introduces the mindfulness practices taught in clinical and other contexts, it notes how the style of teaching bears upon what is learned, and it describes the MBA s approach to cognitive training. The Mindfulness-Based Approaches Much of the interest in the clinical applications of mindfulness emerged from the introduction of MBSR, a manualised treatment programme that developed in a behavioural medicine context for the management of chronic pain (Kabat-Zinn, 1982). The most frequently cited method of mindfulness training (Baer, 2003), MBSR is now widely used to treat the psychological effects associated with chronic illnesses as well as emotional and behavioural disorders (Kabat-Zinn, 1998). The Center for Mindfulness in Medicine, Health Care and Society (CFM), where MBSR began in 1979, had by 1999 delivered the programme to over 10,000 patients, and the teaching of MBSR has extended into prisons, poor inner-city areas, to groups such as medical students, as well as into corporate settings (Crane, 2004). As of 1999 there were 240 centres in the USA offering MBSR programmes (Baer, 2003). MBCT combines training in mindfulness meditation with cognitive therapy (Segal et al., 2002). A large multi-site randomised controlled trial has shown that this approach can significantly reduce the rate of relapse in recurrent major depression (Teasdale et al., 2000). The UK s National Institute for Clinical Excellence (NICE) currently recommends that MBCT be considered for people who are currently well but have experienced three or more previous episodes of depression, because this may significantly reduce the likelihood of future relapse. (NICE, 2004, p.35) Recent innovations in psychological treatment have also led to an increase in the use of mindfulness-based approaches. Dialectical Behaviour Therapy (DBT) (Linehan, 1993a), has been